Failure to Assess Bolsters as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of bolsters as a potential physical restraint for a resident. According to the facility's own restraint policy, any device that restricts a resident's freedom of movement and cannot be easily removed by the resident should be evaluated as a possible restraint. In this case, a resident with a history of falls, decreased safety awareness, altered cognition, and impulsivity was observed lying in bed with bolsters on both sides. The resident's care plan included the use of bilateral bolsters and other fall prevention interventions, but there was no documentation of an assessment or ongoing evaluation to determine if the bolsters functioned as a restraint for this individual. Review of the clinical record and staff interviews confirmed that the facility did not conduct the required comprehensive review or use the Enabler Restraint Observation tool to assess whether the bolsters restricted the resident's movement. Additionally, there was no evidence that the interdisciplinary team evaluated the risks and benefits, considered alternatives, or involved the resident and family in decision-making regarding the use of bolsters. This lack of assessment and ongoing evaluation was acknowledged by the DON during the survey process.